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This thesis draws together a series of publications that were based on research studies conducted between 1981 and 2011, covering care homes and alternative forms of housing with care. The majority of the studies were funded by the Department of Health or its predecessors, and were aimed at responding to policy issues, particularly for local authority grant funding. However, the funding provided the opportunity to collect information for broader purposes, and a central feature linking the studies was the collection, as far as possible, of consistent information about the characteristics of residents over time. The thesis includes 12 pieces of work, based on information collected in ten studies, and illustrates the changes in care home provision from 1981 onwards, and the potential role of alternative forms of housing with care. The aim of the thesis is to explore the following themes: the changing role of care homes and the development of the independent sector, particularly the private sector; factors associated with care home costs; changes in the relative role of residential and nursing homes, including changes in the characteristics of residents over time; changes in the quality of provision; the impact of care home closures; provision for self-funders and the expectations of residents; and the development of alternative forms of housing with care, and the degree to which specialised housing can provide an alternative to residential care. Care homes in the UK provide around 470,000 places and account for over half the expenditure on social care for older people in England. However, information about care facilities and residents is very limited. The papers presented here aimed to fill some of the gaps in understanding residential care and possible alternatives by making use of data collected in a unique series of related research studies conducted over a period of 30 years.

Background: Many interventions aim to alleviate well-documented problems of malnutrition in residential care homes and improve residents’ health and wellbeing. Despite some positive findings, little is known about how and why mealtime interventions might be effective, and in particular, what effects residents’ experiences of mealtimes have on health outcomes. Aim: The aim of this project was to gain an insight into residents’ experiences of mealtimes in order to inform the development of a mealtime intervention. By addressing the issues that impact on residents’ enjoyment of meals, interventions may target improvements in the health and wellbeing of residents more effectively. Methods: This thesis is comprised of three pieces of empirical work conducted using multiple methods. In a systematic review of stakeholder perceptions of mealtimes, five databases were searched from inception to November 2015, followed by thematic analysis of extracted data. In a second study, semi-structured interviews were conducted with eleven residents from four care homes in the South West UK. Thematic analysis was used to derive content and meaning from transcribed interviews. These studies informed the development of a staff-focussed training programme (study three) using the process of Intervention Mapping (IM) as a guide. The feasibility of this intervention was assessed using qualitative surveys and analysed using multiple methods. Fourteen staff from two care homes participated in the feasibility study, which investigated the deliverability of the training programme and the acceptability of its content. Findings: The systematic review and resident interview study revealed that the dining experience was a focal point for residents’ broader experiences of residing in a care home. Whilst meal quality and enjoyment impacted on the dining experience, the provision of care was pivotal in determining mealtime culture and resident agency within the home. This had implications for self-efficacy and social relationships, particularly in the context of transitioning from independent living to a care home community. These findings informed the development of a mealtime intervention, which was found to be deliverable and acceptable to staff. Conclusion: Mealtimes are a mainstay of life in a care home through which residents’ experiences are characterised, exemplified and magnified. Understanding how residents interact with one another, accommodating their preferences and encouraging autonomy may enhance their mealtime experiences. Evidence from the empirical work supports the development of interventions aimed at mealtime staff to improve resident self-efficacy. This thesis has established the necessary groundwork for a pilot trial and future definitive trial to assess resident (and staff) outcome measures including social (e.g., collective engagement) and psychological outcomes (e.g., wellbeing), as well as health outcomes (e.g., nutritional status).

The Palliative and Therapeutic Harmonization (PATH) program was designed to help frail older adults and their family members prepare for and make medical decisions, in the context of frailty and dementia. This sandwich thesis includes three manuscripts that present the findings from a mixed methods study exploring the implementation and outcomes of the PATH program, in three long-term care (LTC) home settings. The purpose of the first sub study was to describe both the perceived need for the PATH program, and initial reactions following its training and implementation. Quantitative surveys and qualitative interviews with bereaved family members showed that prior to implementation, they were mostly satisfied with their relatives’ end-of-life care. Through qualitative interviews, clinical leaders shared a positive impression of the training and PATH principles. They also explained how the PATH program could help them improve palliative and end-of-life care planning and communication with residents and families. In the second sub study, qualitative interviews were conducted with family members to learn about their experiences with and perceived outcomes from the PATH program. All family members had a positive experience. They shared perceived outcomes such as, opportunities to share and learn about their relative’s health status and trajectory, creating a mutual understanding of directions for care, and receiving support and reassurance for health care decision making. Finally, the purpose of the third sub study was to describe both the perceived outcomes of the staff who implemented the PATH program, and differences in documenting residents’ advance care plans and discussions. Staff described both personal and practice related outcomes. In addition, documentation around advance care planning changed with the program’s implementation. Overall, the PATH program offered frail older adults, their family members and their professional caregivers an opportunity to communicate about and prepare to make decisions for palliative and end-of-life care. / Dissertation / Doctor of Philosophy (PhD)

Care home admission following acute hospitalisation is a lived reality across Scotland, experienced by over 8,000 people annually. The aim of this thesis was to develop an understanding of new care home admission following acute hospitalisation. Methods and findings from the mixed-methods approach are presented in three parts. Part One: Identifying relevant research - includes a review of quality assessment tools for systematic reviewing; a systematic review and meta-analysis of quantitative data from observational studies of predictors of care home admission from hospital; and a methodological chapter on developing a search filter to improve accessibility of existing research findings supported by the findings of an international survey of care home researchers. The systematic review identified 53 relevant studies from 16 countries comprising a total population of 1,457,881 participants. Quantitative synthesis of the results from 11 of the studies found that increased age (OR 1.02 per year increase; 95%CI 1.00-1.04), female sex (OR 1.41; 95%CI 1.03-1.92), dementia & cognitive impairment (OR 2.14; 95%CI 1.24-3.70) and functional dependency (OR 2.06; 95%CI 1.58-2.69) were all associated with an increased risk of care home admission after hospitalisation. Despite international variation in service provision, only two studies described the model of care provided in the care home setting. The survey identified that there is a lack of shared terminology in the published literature to describe settings for adults who are unable to live independently in their own homes and require care in a long-term institutional setting. A search filter to identify relevant research could help to overcome differences in terminology and improve synthesis of existing research evidence. Part Two: Exploring current clinical practice - reports the findings of a retrospective cohort study of new care home admissions from hospital using case-note review methodology accompanied by findings from inductive thematic analysis of a single dataset from a qualitative case study design exploring the experiences of a patient, their family, and practitioners (n=5). The cohort study (n=100) found a heterogeneous picture with long hospital admissions (range 14-231 days), frequent transfers of care (31% experienced three or more transfers), varied levels of documented assessment and a lack of documented patient involvement in the decision-making processes. The qualitative interviews allowed the patient voice to emerge, alongside the professional and family narrative which dominated case-note documentation. Inductive thematic analysis identified nine major themes exploring how decisions are made to discharge individuals directly into a care home from the acute hospital setting: biography & personality; professional role; family role; limitations in local model of care; ownership of decision; risk; realising preferences; uncertainty of care home admission process; and psychological impact of in-hospital care. Part Three: Harnessing routinely-collected data - includes the challenges of identifying care home residency at admission and discharge from hospital, presenting analysis of the accuracy of Scottish Morbidity Record 1 (SMR01) coding in NHS Fife and the Community Health Index (CHI) Institution Flag in NHS Fife and NHS Tayside. This is followed by a descriptive analysis of the Scottish Care Home Census (2013-16) as a novel social care data source to explore care home admissions from hospital and the methodology for a data linkage study using these data. Identifying care home residents in routine data sources is challenging. In 18,720 admissions to NHS Fife, SMR01 coding had a sensitivity of 86.0% and positive predictive value of 85.8% in identifying care home residents on admission. At discharge the sensitivity was 87.0% and positive predictive value was 84.5%. From a sample of 10,000 records, the CHI Institution Flag had a sensitivity of 58.6% in NHS Fife and 89.3% in NHS Tayside, with positive predictive values of 99.7% and 97.7% respectively. From 2013-16, of 21,368 admissions to care homes in Scotland, 56.7% were admitted from hospital. There was significant regional variation in rates of care home admission from hospital (35.9-64.7%) and proportion of Local Authority funded places provided to admissions from hospital (34.4-73.9%). Those admitted from hospital appeared to be more dependent and sicker than those admitted from home. This thesis has established a series of challenges in how care homes and their residents are identified. It has questioned the adequacy of the evidence to guide practitioners and sought to raise the profile of this vulnerable and complex population and how best to support them in making decisions regarding admission from the acute hospital. It has progressed our understanding of this under-explored area and proposes a programme of future mixed-methods research involving patients, families, practitioners and policy-makers.

In the planning and delivery of services the voice and choice of consumers have appeared as the foremost key factors. For a large number of organisations the received feedback from customers about the quality of services, which are the criteria and indication of their level of satisfaction play a crucial role in the improvement of quality. Although across developed western communities, the importance of customers’ views has gained acceptance, few studies have been dedicated to the exploration of the voice of the residents in care homes. The review of the literature regarding residents’ satisfaction and quality in care homes revealed that the voices of residents in care homes are usually not heard or are absent. Moreover, the adoption of quality improvement tools in health care has lagged behind that in other industries and there is generally a failure to use an appropriate methodology in care homes, one based on residents’ voice, for improving quality. As a result, the main aim of this research is to investigate residents’ voice regarding improving their satisfaction in care homes. Further, the researcher seeks to obtain data by using an appropriate methodology to assist care home managers in enhancing the quality of the services they offer by assigning weights to quality indicators pertaining to improving quality and residents’ levels of satisfaction. For this purpose, this research employs both qualitative and quantitative approaches to develop a research process entailing: (1) a comprehensive literature review to recognise the phenomenon; (2) interviews with fifteen older people who lived in three different care homes in order to discover the most important residents’ needs and requirements in such homes; (3) a resident survey with one hundred and two residents in thirty five care homes. These were conducted to assess their preferences for the importance of demanded qualities; their satisfaction with provided services and the attributes of each demanded quality based on the Kano model, in order to identify the priority of improvement. Next, (4) there was the development of the House of Quality (HoQ) to optimize quality to assure residents’ satisfaction; and finally, (5) an evaluation study was conducted with thirteen service providers, in order to assess the accuracy and appropriateness of the methodology. This research has contributed towards a better understanding of the residents’ voice, and applying it for enhancing quality and residents’ satisfaction in care homes. For the first time residents’ requirements are prioritised and classified in this context through accurate methods. Moreover, an understanding of the attributes of care home residents’ needs in relation to a Kano model has been elicited. The novelty of this proposed methodology is in utilising the Quality Function Deployment (QFD) in care homes to translate the voice of residents’ regarding their requirements into service planning. The research methodology and results facilitate care home managers with a hierarchy for improvement planning at both service and executive management levels.

Traditional familial care has been challenged due to the reduction of family size and increased mobility of the Chinese population. Institutional elder care is increasingly becoming an alternative to familial care. This study explores the relationship between ownership of elder care home and care quality, using data collected in 2010 from 157 homes in Tianjin. Two hypotheses were proposed for the study: 1) There is a difference between government and non government-owned facilities in facility characteristics; 2) Government-owned facilities have better care quality outcomes. The t-test results showed that government-owned elder care homes had advantages in economic resources, staffing and the availability of services. Government-owned facilities reported lower mortality rate compared to non government-owned facilities. Multi-variant regression analysis showed that economic resources—whether funding from the government or high payments from care-recipients in private facilities--are important factors predicting higher levels of care quality. These results indicate that the Chinese government continues to play an important role in institutional long term care; in the meantime, private market is increasing its prominence in the long term care market.

Personal care homes have become increasingly dependent on the employment of immigrant care workers. This qualitative study explored the high concentration of Filipino health care aides in personal care homes from their own perspectives, as well as that of policy stakeholders. In depth interviews were conducted with seven Filipino health care aides working in personal care homes in Winnipeg, Manitoba. Semi-structured interviews with policy stakeholders examined the policy context of the health care aide labour force. The study identified several factors that influenced the migration and employment of Filipino health care aides including: poverty and unemployment, migrant social networks, barriers in the labour market and financial incentives. The lack of regulations for health care aides sustained the flow of immigrant labour and enabled the expansion of social networks. Although their employment decisions were primarily based on financial need, health care aides valued their work and viewed themselves as critical care providers.

Falls among older adults (age 65 years and older) residing in personal care homes (PCHs) are an important health concern. Atypical antipsychotic drugs (AADs) have been shown to be associated with fall risk among older adults. However, previous studies face some methodological limitations that affect the quality, consistency, and comparability of these studies. Therefore, a population-based study was undertaken to examine the effect of AAD use on the risk of falling among older PCH residents. A nested case-control study was conducted using the administrative healthcare records and Minimum Data Set for PCHs (MDS) housed at the Manitoba Centre for Health Policy in the Faculty of Medicine, University of Manitoba. The study period was from April 1, 2005 to March 31, 2007. Cases (n=626) were fallers as recorded in MDS. Using incidence density sampling, each case was matched to four controls on length of PCH stay, age, and sex (n=2,388). Exposure to AADs was obtained from the Drug Program Information Network database. Conditional logistic regression was used to model the effects of AAD use on the risk of falling while accounting for matching and for confounding of other covariates. While the adjusted odds of falling was statistically greater for AAD users versus nonusers (adjusted odds ratio = 1.60, 95% CI 1.10-2.32), this association was type and dose dependent. Compared to nonusers, the odds of falling was greater for quetiapine users, regardless of this drug's dose, and high dose risperidone users. On the other hand, low dose risperidone and olanzapine, irrespective of drug dose, use was not associated with the risk of falling. Furthermore, the effect of AAD use, in general, on the risk of falling was significantly greater for people with wandering problems (adjusted odds ratio = 1.84, 95% CI 1.09-3.09). Despite some methodological limitations, this research has provided some unique findings that enhance our understanding of AAD use as a fall risk factor. Study findings allow policymakers to further develop evidence-based interventions specific to AADs in order to better manage falls in the PCH setting. However, a great deal of research is still needed to address other important unanswered questions.

Personal care homes have become increasingly dependent on the employment of immigrant care workers. This qualitative study explored the high concentration of Filipino health care aides in personal care homes from their own perspectives, as well as that of policy stakeholders. In depth interviews were conducted with seven Filipino health care aides working in personal care homes in Winnipeg, Manitoba. Semi-structured interviews with policy stakeholders examined the policy context of the health care aide labour force. The study identified several factors that influenced the migration and employment of Filipino health care aides including: poverty and unemployment, migrant social networks, barriers in the labour market and financial incentives. The lack of regulations for health care aides sustained the flow of immigrant labour and enabled the expansion of social networks. Although their employment decisions were primarily based on financial need, health care aides valued their work and viewed themselves as critical care providers.